The Problem With Pain Pills

By TARA PARKER-POPE

June 26, 2013

In the new e-book “A World of Hurt: Fixing Pain Medicine’s Biggest Mistake,” the New York Times reporter Barry Meier explores the murky world of prescription pain medicine. He makes a strong case that opioid drugs used to treat chronic pain, like OxyContin, not only are addictive and deadly but often don’t work for many people who use them and lead to a range of additional health problems.

It’s Mr. Meier’s second foray into the complicated world of pain relief. His first book, “Pain Killer: A ‘Wonder’ Drug’s Trail of Addiction and Death,” focused on the potential for abuse of OxyContin, particularly by teenagers. In the new, shorter e-book, Mr. Meier focuses on the long-term consequences of widespread use of opioid drugs to treat pain. I recently spoke with Mr. Meier about the problems associated with painkillers, why doctors and patients resist giving them up and some of the surprising side effects of these drugs. Here’s our conversation.

Q.

Why did you decide to revisit the topic of opioid painkillers?

A.

I wrote a book 10 years ago about the rise of OxyContin and the pain management industry. That book was focused on abuse. The prevailing medical notion was that there was this bright line involving the opioids — that they were great for patients but the problems happened when they went out on the streets and were abused by kids and others. But today it’s clear that the long-term use of these drugs can not only be ineffective for chronic pain, but they also create bad side effects for patients. Not just addiction but powerful psychological dependency, depression of hormone production, lethargy and listlessness and sleep apnea, among others. These drugs do work well for some patients, but for many other patients, they’re not working well at all.

Q.

What made you realize that more needed to be written about the consequences of these drugs?

A.

There were two powerful factors. The number of annual overdose deaths from narcotic painkillers has grown four times higher than it was a decade ago. The current statistic is that about 16,000 people a year die of overdoses involving prescription narcotics. The thing that was even more powerful for me was the growing realization that there are risks of these drugs for patients themselves, not just for people who are out-and-out abusing these drugs. People taking these drugs as directed have far more significant negative consequences than have been previously appreciated. It became of question of, “How are we treating chronic pain over the long term and are these drugs really the answer?”

Q.

Given these concerns, why are opioid pain relievers like OxyContin the drug of choice for doctors and patients?

A.

Insurers and government agencies seized on opioids much like the use of antidepressants for psychological problems. Drugs are cheaper than talk therapy. Drugs are cheaper than a multidisciplinary approach to chronic pain. Doctors get reimbursed to treat people quickly, so funding for other approaches is cut out. These drugs became the treatment method of choice.

Q.

Are doctors beginning to question the use of these drugs now?

A.

There is probably a real shift going on in the medical community. There have been increasing questions raised, even among those who once promoted the drugs, that they are not the panacea to treating chronic pain. One leading expert said: “We thought the big problem with these drugs is addiction. Now we realize the problem is with patients who take them and basically opt out of life.” There is a general realization that while they do work for some patients, using them on a massive scale to treat chronic pain has had really disastrous consequences.

Q.

What is it about these drugs that creates such concern?

A.

You look at things like disability statistics — one of the biggest indicators of disability is use of these drugs. For instance, back pain is probably the leading workplace injury. What insurers and workers’ comp agencies are discovering is that when workers are treated with high doses of opioid drugs fairly soon after these injuries, it’s the leading predictor for them not coming back to work for long periods of time, or ever.

These drugs have a very powerful impact on our production of sexual hormones — testosterone in men and estrogen in women. Lower hormone production is not just about growing hair or sexual performance; it’s about your entire energy level. These drugs are depleting people of energy. There are even data showing that the more powerful opioids, the long-acting OxyContin, methadone, fentanyl, which is sold as Duragesic, have an even more powerful effect on depressing hormone production than short-acting opioids. These drugs are not just blocking pain receptors so you don’t feel pain; they are having powerful systemic effects on people,

Q.

You also make the point that these drugs can actually lead to more pain. How does that happen?

A.

When you take a narcotic painkiller it sets off a natural reaction called tolerance, which means your body adjusts to it. You have to take more of the drug to get the same painkilling effect. Patients would come back to doctors and say, “This drug was working really well for me, but now I’m feeling pain again.” The doctor would increase the dose. The prevailing ideology during the war on pain was that these drugs had no ceiling dose. You could keep increasing them. The doctors kept boosting them every six months. People started taking higher and higher doses of these drugs. At a certain point it appears they create a change in the neurological system where people develop hyperalgesia and they become far more sensitive to pain than when they started out on these drugs.

Q.

So what is a person who has chronic pain supposed to do?

A.

There was an interesting German research study earlier this year that looked at what happened when people are weaned off these drugs to a nondrug treatment plan. When they are weaned off high levels of opioids, they experienced less pain than when they were on high doses.

Part of the reason for writing this book is there is an antidote to dependence on these drugs. There are plenty of data suggesting that a multidisciplinary approach to chronic pain works as effectively as high-dose opioid treatment. Patients experiencing chronic pain for whatever cause will be put through a program where they receive intensive physical therapy, behavioral counseling, intensive psychological counseling.

One of the problems with chronic pain – there’s a lot of catastrophizing around it. People think this is the way it’s going to be for the rest of their life, and that they are trapped in this horrible pain and it’s only going to get worse. There is tremendous anxiety associated with that. They not only end up taking pain drugs and strong narcotics, but they take a lot of anti-anxiety medications as well.

The whole focus on multidisciplinary programs is to get people functioning again. One of the big drawbacks of long-term opiate use is many people who take these drugs over a long period of time lose physical function. The goal is to restore physical function and to help people learn if they do have chronic pain conditions, they may experience pain for the foreseeable future, but that is not necessarily a barrier to prevent them from living a full, active life.